Medication vs. Therapy for OCD: How to Decide from a Therapist's Perspective

Patient meets with their therapist. Connect with a therapist at La Jolla Therapy Center to support you in managing OCD symtpoms.

My client sat in my office, her foot tapping anxiously against the floor. “I just don’t know what to do,” she admitted. “Should I try therapy? Should I take medication? Should I do both? Or maybe I should just move to the mountains and raise llamas?”

I laughed a bit. “Llamas are great, but let’s talk through your options first.”

Deciding between therapy and medication for obsessive-compulsive disorder (OCD) can feel overwhelming, like trying to choose between two equally suspiciously long receipts at CVS. Both approaches have their strengths, and what works best depends on the individual. So, let’s break it down—without the anxiety-inducing fine print.

Understanding the Role of Therapy in OCD Treatment

Therapy, particularly cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP), is considered the gold standard for OCD treatment. ERP involves gradually exposing clients to feared thoughts or situations while preventing compulsive responses. Over time, this helps reduce anxiety and break the cycle of obsessions and compulsions.

Another effective therapy approach is Acceptance and Commitment Therapy (ACT). Unlike ERP, which focuses on reducing symptoms through exposure, ACT helps individuals accept distressing thoughts and emotions without trying to control them. ACT teaches mindfulness skills and values-based action, helping clients create a meaningful life alongside their OCD symptoms rather than being controlled by them.

Benefits of Therapy for OCD

1. Long-Term Effectiveness 

ERP and ACT target the root of OCD symptoms, helping clients develop lasting coping strategies rather than just managing symptoms.

2. Skill-Building 

Therapy equips clients with tools to manage distress, tolerate uncertainty, and reduce avoidance behaviors.

3. No Side Effects 

Unlike medication, therapy does not cause physiological side effects.

4. Personalized Approach 

Therapy can be tailored to each individual’s triggers and severity level.

5. Addresses Underlying Issues 

Many clients with OCD also struggle with perfectionism, trauma, or comorbid anxiety disorders. Therapy can help address these underlying factors.

Challenges of Therapy

1. Time-Intensive

ERP requires consistent effort, homework, and repeated exposure exercises, which can be emotionally challenging.

2. Initial Increase in Anxiety 

Facing fears without engaging in compulsions can temporarily heighten anxiety before improvement occurs.

3. Limited Accessibility 

Trained OCD specialists can be difficult to find, and therapy may be expensive or not covered by insurance.

Understanding the Role of Medication in OCD Treatment

Selective serotonin reuptake inhibitors (SSRIs) and, in some cases, serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed for OCD. Fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) are among the first-line medications. In more severe cases, antipsychotic medications may be used as augmenting agents.

Benefits of Medication for OCD

1. Reduces Symptoms 

Medication can significantly reduce the intensity of intrusive thoughts and compulsions, especially for those with moderate to severe OCD.

2. Can Work Relatively Quickly 

Some individuals notice improvement within a few weeks, though full effects may take 8-12 weeks.

3. Accessible Treatment Option 

Unlike ERP, which requires a trained specialist, medication can be prescribed by primary care physicians or psychiatrists.

4. Beneficial for Severe Cases 

When OCD symptoms are so severe that they prevent participation in therapy, medication can help stabilize symptoms enough for a person to engage in ERP or ACT.

Challenges of Medication

1. Side Effects

Common side effects include nausea, weight gain, sexual dysfunction, and sleep disturbances.

2. Does Not Address Underlying Thought Patterns 

Medication can reduce symptoms but does not change maladaptive thought processes like therapy does.

3. Dependency Concerns 

Some individuals may rely solely on medication without developing coping mechanisms, leading to symptom recurrence if they stop taking it.

4. Trial and Error Process 

Finding the right medication and dosage can take time, and not everyone responds well to SSRIs.

How to Decide: Medication, Therapy, or Both?

Deciding between medication and therapy—or a combination of both—depends on several factors, including severity of symptoms, personal preferences, and previous treatment experiences. As a therapist, these are key considerations when helping clients decide:

1. Severity of Symptoms

• Mild to Moderate OCD – Therapy alone, particularly ERP and/or ACT, is often the best approach, as it provides lasting benefits and teaches individuals how to manage their symptoms.

• Moderate to Severe OCD – A combination of therapy and medication may be the most effective, especially if symptoms interfere with daily functioning.

• Severe or Treatment-Resistant OCD – Medication may be necessary to stabilize symptoms before engaging in therapy.

2. Client Readiness and Preferences

Some clients may feel apprehensive about taking medication due to concerns about side effects or stigma. Others may struggle with the intensity of ERP and prefer to start with medication. A client-centered approach respects these preferences while providing education about the effectiveness of both options.

3. Past Treatment History

If a client has previously tried therapy without success, adding medication may enhance their ability to engage in ERP and/or ACT. Conversely, if medication alone has not led to significant improvement, incorporating therapy can provide additional tools for managing OCD.

4. Comorbid Conditions

Many individuals with OCD also experience depression, generalized anxiety disorder, or ADHD. The presence of co-occurring conditions may influence treatment choice. For example, if a client has severe depression, medication may be necessary to improve motivation and emotional regulation before therapy.

5. Practical Consideration

• Access to ERP or ACT Specialists – If a trained therapist is not available, medication may be a more immediately accessible option.

• Financial and Insurance Coverage – Some clients may choose medication due to financial constraints, while others may prioritize therapy if they have the means to afford it.

The Case for a Combined Approach

Research suggests that the combination of medication and therapy can be particularly effective for individuals with moderate to severe OCD. Medication can help reduce symptoms enough to enable participation in therapy, while therapy provides long-term skills to maintain progress. In many cases, clients can eventually taper off medication while continuing to use ERP or ACT techniques for lasting results.

Final Thoughts

My client sighed, looking a little less overwhelmed. “So, maybe I’ll hold off on the llamas for now?”

I smiled and said, “Let’s start with some therapy and see how you feel.”

As a therapist, helping clients navigate the decision between medication and therapy involves balancing scientific evidence with individual circumstances. While ERP remains the gold standard for lasting change, ACT offers an alternative for individuals who struggle with traditional exposure methods. Medication can play a vital role in symptom management, especially for those with severe OCD. The best approach is one that aligns with the client’s needs, preferences, and ability to engage in treatment. By providing education, support, and a collaborative decision-making process, therapists can empower clients to choose the path that leads to the most effective and sustainable recovery.

Our San Diego, California based counseling practice specializes in helping teens and adults who struggle with anxiety. Through counseling, we help kids and young adults overcome the negative thought cycles, the constant comparison game, and worst-case scenarios that accompany the anxious brain. Additionally, we offer other mental health services, primarily for perfectionists, overachievers or others who don’t feel like they 100% fit in. More specifically we offer treatment for anxiety/OCD, and depression at La Jolla Therapy Center. If you don’t live around San Diego or the commute makes in-person therapy impossible, all of our services are available via online therapy to anyone physically located in California. Therefore, we work with clients from Sacramento to Palo Alto or even Mountain View. You and your family deserve to finally feel less overwhelmed, so let’s get started!